Assessment

HISTORY. Because patients (especially children) with asthma have a history of allergies, obtain a thorough description of the response to allergens or other irritants. The patient may

108 Asthma describe a sudden onset of symptoms after exposure, with a sense of suffocation. Symptoms include dyspnea, wheezing, and a cough (either dry or productive) and also chest tightness, restlessness, anxiety, and a prolonged expiratory phase. Ask if the patient has experienced a recent viral infection. Children with an impending asthma attack may have been vomiting because of the tendency to swallow coughed up mucus rather than expectorating it.

PHYSICAL EXAMINATION. The patient with an acute attack of asthma appears ill, with shortness of breath so severe that he or she can hardly speak. In acute airway obstruction, patients use their accessory muscles for breathing and are often profoundly diaphoretic. Some patients have an increased anteroposterior thoracic diameter. Children with asthma often prefer standing or sitting leaning forward to ease breathing. As airway obstruction becomes more serious, children may develop sternocleidomastoid contractions that indicate an increased expiratory effort, supraclavic-ular contractions that indicate an increased expiratory effort, and nasal flaring. If the patient has marked color changes such as pallor or cyanosis or becomes confused, restless, or lethargic, respiratory failure may be on the horizon. Percussion of the lungs usually produces hyper-resonance, and palpation may reveal vocal fremitus. Auscultation reveals high-pitched inspiratory and expiratory wheezes, but with a major airway obstruction, breath sounds may be diminished. As the obstruction improves, breath sounds may actually worsen as they can be auscultated throughout the lung fields. Usually, the patient also has a prolonged expiratory phase of respiration. A rapid heart rate, mild systolic hypertension, and a paradoxic pulse may also be present.

PSYCHOSOCIAL. The emergency situation and an unfamiliar environment can aggravate the symptoms of the disease, especially if this is the patient's first experience with the condition. If the patient is a child and the parent is anxious, the child's level of anxiety increases and the attack may worsen.

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